EFFECTS OF COGNITIVE THERAPY AND FAMILY

PSYCHOEDUCATION IN STROKE CLIENTS WITH DEPRESSION AND

DISABILITY

ABSTRACT

Stroke patients who were take care in the hospital 30-40% in

depression condition. This research aim was to determine the effect of
cognitive therapy and psycho Education for depression, helplessness,
and ability to change negative thoughts for stroke patients. This
research design was quasi experimental pre and post test with control
group with a total of sample 87 person with 29 persons are given
cognitive therapy and family psychoeducation therapy, 29 persons are
given only cognitive therapy and 29 persons are not given therapy.
Analysis by anova test and Pair t-test. The result of research show a
decrease in depression and helplessness condition and increase the
ability to change negative thoughts of stroke clients whom received
cognitive therapy and family psychoeducation group larger than whom
just only receive cognitive therapy and the group without therapy (p
value <0,05). There was factor that contribute depression condition of
stroke client is age. Cognitive therapy and Family Psychoeducation are
recommended for stroke klien who got depression and helplessness.

Keyword : depression; helplessness; Cognitive therapy and Family

Psycoeducation

INTRODUCTION

Stroke is a description of neurological changes as a result of

pathological processes in the blood vessel system by thrombosis or
embolism, rupture of brain blood vessel walls, changes in blood vessel
wall permeability and changes in viscosity and blood quality itself
(Misbach, 2011). Stroke ranks as the third leading cause of death after
heart disease and cancer in the United States (Misbach, 2011).
According to WHO in 2007 as many as 15 million people suffered a
stroke worldwide each year. Of these 5 million people died and 5
million more suffered permanent disabilities. High blood pressure is the
leading cause of stroke worldwide, namely 12.7 million (WHO, 2007).
Basic Health Research data in 2007 shows the prevalence of the number
of stroke sufferers reaching 8.3 per 1,000 population in Indonesia. The
population in Indonesia is around 211 million people, meaning there
are about 1.7 million stroke sufferers. Stroke is the highest cause of
death with a rate of 15.4% (Riskesdas, 2007). Riskesdas 2018, the
prevalence of the number of stroke sufferers increased by 10.9 per mil.

Stroke clients have higher rates of depression and anxiety than people
without chronic disease (WFMH, 2010). In stroke patients, depression
occurs 10-25% for women and 5-12% in men. The results showed that
about 30-40% of stroke clients who were hospitalized experienced
depression (Suparyanto, 2012).

Depression experienced by individuals with chronic illnesses can

increase the burden of physical illness and somatic symptoms, increase
functional impairment and increase medical costs. Many studies show
that depression often causes changes that can worsen the physical and
emotional condition of people with physical illnesses (WFMH, 2010).
The results showed that around 30-40% of stroke clients who were
hospitalized experienced depression (Suparyanto, 2012).

Depression is a prolonged or abnormal sadness and grief (Stuart, 2009).

Depression is characterized by a decreased mood, loss of interest or
pleasure. The client feels sad, hopeless, sad or worthless. Symptoms of
depression include fatigue, inability to concentrate / create
decisions, feeling sad, worthless / guilty (Sadock & Sadock, 2010).
According to WHO, depression is a mental disorder that is usually
followed by feelings of sadness, loss of interest or pleasure, decreased
energy, feelings of guilt or inferiority, disturbances in sleep patterns or
appetite and lack of concentration.

Nursing problems that can arise in stroke are anxiety, low self-esteem,
helplessness, hopelessness, social isolation, ineffective individual coping
(Copel, 2007). Common psychological disorders that arise in stroke
clients include ineffective individual coping, anxiety, social isolation,
changes in self-concept and helplessness. (Misbach, 2011). Dependence
on other people can lead to irritability, anger, guilt and dissatisfaction
with the inability to carry out previous activities (Nanda, 2009).
Therapies that can be given to stroke clients who experience depression
and helplessness are cognitive therapy and family psychoeducation.
Cognitive therapy can help stop negative thought patterns and help
sufferers fight depression because this therapy aims to change negative
thoughts into positive ones, find out the causes that are felt, help self-
control and prevention and personal growth (Burns, 1988). Research
related to cognitive therapy conducted by Kristyaningsih, Keliat, Helena
(2009) showed that the level of self-esteem increased more significantly
and depressive conditions decreased more significantly in the group of
chronic kidney failure clients who received cognitive therapy compared
to the group of chronic kidney failure clients who did not receive
cognitive therapy.

Powerlessness is a condition in which an individual or group feels that

they lack control over a person or situation that has an impact on views,
goals and lifestyle (Carpenito, 2010). Powerlessness is the biggest
impact of chronic disease as a result of self-acceptance and changes in
the lifestyle of clients with chronic diseases. In dealing with chronic
disease, an adaptive coping mechanism is needed as an effort to prevent
the development of stressors into maladaptive conditions that can cause
chronic disease sufferers to experience helplessness against the disease
they are experiencing (Miller, 2004).

Therapies that can be given to stroke clients who experience depression

and helplessness are cognitive therapy and family psychoeducation.
Cognitive therapy can help stop negative thought patterns and help
sufferers fight depression because this therapy aims to change negative
thoughts into positive ones, find out the causes that are felt, help self-
control and prevention and personal growth (Burns, 1988). Research
related to cognitive therapy conducted by Kristyaningsih, Keliat, Helena
(2009) showed that the level of self-esteem increased more significantly
and depressive conditions decreased more significantly in the group of
chronic kidney failure clients who received cognitive therapy compared
to the group of chronic kidney failure clients who did not receive
cognitive therapy.

Sarfika's research, Keliat, Wardani (2012) states that cognitive therapy

can significantly increase the ability to change negative thoughts,
cognitive therapy and logotherapy can increase the ability to interpret
life more than cognitive therapy. Family Psychoeducation therapy is one
element of the family mental health care program by providing
information and education through therapeutic communication
involving families. Family Psychoeducation is a specialist therapy that is
appropriate to be given to families with family members who
experience health problems, both physical and mental illnesses.
Research related to family psycho education conducted by Nurbani,
keliat & Harahap (2009) shows that anxiety is the result of self-
evaluation and observation with anxiety. and observation decreased
compared to before being given psychoeducation while the burden
decreased but not significant (p-value> 0.05).

Based on research conducted by Keliat (2006), the recurrence rate in

clients with disorders without family therapy was 25-50%, while the
recurrence rate in clients who were given family therapy was 5-15%.
This means that family support is important in reducing psychosocial
problems that arise in stroke clients through psychotherapy. So that
cognitive therapy and family psychoeducation are given here with the
aim of being able to reduce depression, helplessness and increase the
ability to change negative thoughts in stroke clients.

METHOD
The design of this research is a "quasi experimental pre and post test
with control group" with the intervention of cognitive therapy and
family psychoeducation therapy. The sampling technique is Consecutive
Sampling with inclusion criteria: clients with a stroke diagnosis with a
productive age of 30-69 years, able to communicate well, experiencing
depression (with a score> 10 on the measurement using BDI),
experiencing helplessness, willing to be respondents, accompanied by
family who continuously take care of clients. The sample in this study
consisted of 29 people who received cognitive therapy and family
psychoeducation, 29 people who only received cognitive therapy and 29
people who did not get therapy.

The variables in this study consisted of respondent characteristics,

depression, helplessness and the ability to change negative thoughts.
The instrument used in this study consisted of a questionnaire
containing data on the characteristics of the respondents. Questionnaire
two contains the measurement of depression using the Beck Depression
Inventory scale, questionnaire three contains the measurement of
helplessness where validity and reliability tests are carried out before
the research is carried out with a value of r count> r table (0.361) and a
cronbach alpha coefficient value is obtained, namely 0.735 and
questionnaire four is about measurement. the ability to change negative
thoughts where researchers use instruments that have been tested for
validity and reliability by previous researchers, namely Sarfika (2012).

Univariate analysis was carried out on the characteristics of stroke

clients (age, gender, occupation, education and duration of stroke,
depressive conditions, conditions of helplessness and ability to change
negative thoughts). Analysis of changes in depression, helplessness and
the ability to change negative thoughts using a paired t-test. The
analysis used to see changes in depression, helplessness and the ability
to change negative thoughts between the three groups used the ANOVA
test. To see differences in conditions of depression, helplessness and
ability to change negative thoughts using Bonferroni.

This research was conducted with due observance of the ethical

principles of research (Polit & Back, 2006), which started from
providing an explanation of the research (Informed consent sheet) to
stroke clients who were respondents in this study. The explanation
given is in the form of research objectives, research benefits
(beneficience), research procedures and consequences of being
research respondents as well as a guarantee of research confidentiality
(Confidentiality) by keeping all forms of information and the name of
the respondent confidential where the respondent's name is changed in
code form (Anonymous) which is only known by the researcher.
(attachment 2). After the respondent agrees to be involved in this
research, the respondent signs the consent form to become the
respondent. Respondents' rights are considered in this study where
each respondent is given full rights to approve or refuse to be a
respondent without any sanctions (autonomy). Researchers provide
justice to all respondents both before, during and after the research
takes place (justice) by explaining all research procedures and
providing booklets to respondents who were not given therapy after a
post test.

RESULT

A. Types of stroke clients

Changes in the Depression Condition of the Client Stroke Before
and After the Family Psychoeducation and Cognitive Therapy
Intervention
 Characteristics of stroke clients who were hospitalized in this
study with an average age of 54.58 years, the most sexes who
suffered from stroke were male 55.2%, 52.9% did not work, 54%
were highly educated and had an average length of time. suffered
a stroke 15.49 days.

b. The Effect of Cognitive Therapy and Family Psychoeducation

on Depression Conditions.
Depressive conditions in general before treatment in 87 stroke
clients with an average of 19.14 who were in a moderate
depression condition. There was a significant decrease in
depressive conditions in stroke clients who were given cognitive
therapy and family psychoeducation where the depressive
conditions were in mild depression. The following can be seen a
graph of changes in depressive conditions before and after being
given therapy.
Changes in the depression condition of stroke clients before and after
the CT & FPE intervention

25
20 20.59
19.24 19.34
17.59 16.76
15 13.76 CT &
10 FPE
CT
5 Kontro
l
0
before After

The average depression condition in the group that was given

cognitive therapy and family psychoeducation before the
intervention was 17.59 which was in a moderate depression
condition after being given the intervention the average
depression condition was 13.76 where it was in a mild condition.
The results of statistical tests showed that there was a significant
decrease in the average depression condition before and after
being given the intervention of cognitive therapy and family
psychoeducation (Pvalue <0.05). In the group that was given
cognitive therapy and family psychoeducation, the decrease in
depression condition was 3.83.
 The average depression condition in the group that only received
cognitive therapy before being given the intervention was 19.24
after being given the intervention, the average depression
condition was 16.76 in the moderate depression range. The
results of statistical tests showed that there was a significant
decrease in the average depression condition before and after
being given cognitive therapy intervention (Pvalue <0.05). In the
group that only received cognitive therapy decreased depression
condition decreased 2.48.

The average depression condition in the group that did not get
therapy (control) before 20.59 after giving therapy to the
cognitive therapy and family psychoeducation groups and the
cognitive therapy group averaged 19.34. There was a change in
the mean depression condition before and after therapy in the
cognitive therapy & family psychoeducation group and those
who only received cognitive therapy in the group who did not
receive therapy but it was not significant (Pv> 0.05).

In the group that was given cognitive therapy and family

psychoeducation, the decrease in depression condition was 3.83.
In the group that only received cognitive therapy, the decrease in
depressive conditions decreased by 2.48 and in the group that
did not receive the difference in reduction in depression
conditions by 1.24.

c. The Effect of Cognitive Therapy and Family Psychoeducation

on Depression Conditions.
The condition of helplessness in stroke clients before the
intervention was at a score of 31.08 and showed equivalence with
a value of> 0.05. Based on the research instrument, the score of
helplessness ranged from 13 to 52 for the condition of
helplessness. The following can be seen a graph of changes in
helplessness before and after being given therapy.
Changes in the helplessness condition of stroke clients before and after
the CT & FPE intervention
36
35.41
35
34
33 33.21 CT & FPE
CT
32 31.83 31.72 Kontrol
31 31.07
30 30.34
29
28
27
before after

The average condition of helplessness in the group that was given

cognitive therapy and family psychoeducation before the
intervention was 31.83 with a standard deviation of 4.622 after
being given the intervention the average of helplessness was
35.41 with a standard deviation of 4.171. The results of statistical
tests showed that there was a significant increase in the mean of
helplessness before and after being given the intervention of
cognitive therapy and family psychoeducation (Pvalue <0.05). In
the group that was given cognitive therapy and family
psychoeducation, the difference in the helplessness score
increased by 3.586

The average group that only received cognitive therapy before

being given the intervention was 31.07 with a standard deviation
of 3.817 after being given the intervention the average condition
of helplessness was 33.21 with a standard deviation of 3.178. The
results of statistical tests showed that there was a significant
increase in the average condition of helplessness before and after
being given cognitive therapy intervention (Pv <0.05). In the
group that only received cognitive therapy, the difference in the
increase in the score of helplessness was 2.138

The mean score of helplessness in the group that did not get
therapy (control) before was 30.34 with a standard deviation of
4.328, the mean score of helplessness after giving therapy to the
group that received cognitive therapy and family
psychoeducation and who only received cognitive therapy in the
 group that did not get therapy to be 31.72 with a standard
deviation of 4.697. There was an increase in the mean score of
helplessness before and after being given therapy in the group
receiving cognitive therapy and family psychoeducation and the
group receiving cognitive therapy only in the control group (Pv
<0.05).

d. The Effect of Cognitive Therapy and Family Psychoeducation

on the Ability to Change Negativse Thoughts
The average ability to change negative thoughts in stroke clients
before being given cognitive therapy and family psychoeducation
is at a score of 62.60 and shows equivalence with a value of>
0.05.
Changes in Ability to Change Client's Negative Thought of Stroke
Before and After CT & FPE Intervention
74
72 72.76
72.24
70
68 CT & FPE
66 66.62 CT
64 64.03 Kontrol
62 62.69
61.07
60
58
56
54
before after

The average ability to change negative thoughts in the group

given cognitive therapy and family psychoeducation before the
intervention was 61.07 with a standard deviation of 9.067 after
being given the intervention, the average depression condition
was 72.76 with a standard deviation of 12.557. The results of
statistical tests showed that there was a significant increase in
the average ability to change negative thoughts before and after
being given the intervention of cognitive therapy and family
psychoeducation (Pvalue <0.05). In the group that was given
cognitive therapy and family psychoeducation, the difference in
the increase in the ability to change negative thoughts was 11.69.

The average group that only received cognitive therapy before

being given the intervention was 64.03 with a standard deviation
 of 10.972 after being given the intervention the average
depression condition was 72.74 with a standard deviation of
9.884. The average ability to change negative thoughts in the
group that did not receive therapy before was 62.69 with a
standard deviation of 10.404. The results of statistical tests
showed that there was a significant increase in the average
ability to change negative thoughts before and after being given
cognitive therapy intervention (Pv <0.05). In the group that only
received cognitive therapy increased ability to change negative
thoughts 8,207.

The average condition of the ability to change negative thoughts

before giving therapy in the CT & FPE group and CT in the
control group was 62.38 with a standard deviation of 10.404 to
66.62 with a standard deviation of 11.037. There was a
significant increase in the average ability to change negative
thoughts before and after therapy (Pv <0.05).
In the group that was given cognitive therapy and family
psychoeducation, the increased ability to change negative
thoughts was 11.69. In the group that only received cognitive
therapy an increase in the ability to change negative thoughts
was 8,207 and in the group that did not receive the therapy, an
increase in the ability to change negative thoughts was 3,931.

DISCUSSION
a. The Effect of Cognitive Therapy and Family Psychoeducation
on Depression Conditions.
Depressive conditions in the group that received cognitive
therapy and family psychoeducation decreased significantly and
significantly. The average depression condition in stroke clients
before the intervention was 30.38%. The results of this study are
supported by research conducted by Sarfika, Keliat & Wardani
(2012) which shows that 79% of DM clients who are hospitalized
experience depression. After being given cognitive therapy
intervention and logotherapy, his depression condition
decreased significantly. The decrease in depressive conditions
after being given cognitive therapy and family psychoeducation
was 6.08%. Another study conducted by Pasaribu, keliat &
wardani (2010) showed a significant change in depressive
conditions in the group that received cognitive therapy and
thought-cessation therapy from moderate depression to mild
depression. Depressive conditions arise due to psychological
factors in the form of failures experienced due to physical
weakness in the form of an inability to do work as usual.

Family therapy aims to provide information about illnesses

suffered by family members who are sick. Family
psychoeducation is an important element in a family mental
health program, namely providing information and education
through therapeutic communication (Stuart and Laraia, 2005).
Families need to know what are the impacts that arise from a
stroke experienced by clients in addition to its physical impacts.
So that by knowing the psychological impact experienced by
clients, the family is able to help and remind clients how to deal
with the psychological effects that arise due to physical illnesses
such as depression. In addition, psychological support is needed
to support the healing process of stroke clients. According to
Rahayu (2011), giving FPE increases the family's ability to
provide social psychological support to family members who
have suffered a stroke

The results showed that the depression condition before being

given the intervention of cognitive therapy and family
psychoeducation was 17.92 (27.92%), which was in moderate
depression to 13.76 (21.84%), namely in mild depression. The
results of research by Sarfika, Keliat & Wardani (2012) showed
that there was a decrease in depression after being given
cognitive therapy and logotherapy by 79.4%. The results of
another study conducted by Pasaribu where the depression
condition after giving cognitive therapy and stopping thoughts
decreased by (50.21%). This is different from the results
conducted by researchers where the results of a decrease in
depressive conditions by 6.08% were not too significant for
changes in depressive conditions. Here the depressive condition
decreases from moderate to mild.

Depressive conditions are characterized by clients feeling sad,

hopeless, troubled or worthless. In stroke clients 73-80% of
clients suffer from hemiparesis or hemiplegi. The impact of this
disability causes limitations to stroke clients in carrying out
activities. Clients tend to depend on other people. The client feels
helpless due to the physical condition he is experiencing. The
recovery process from this disability condition takes a long time.

The results showed that cognitive therapy alone could reduce

depression in stroke clients, namely 19.24 (30.53%) to 16.76
(26.55%), namely 3.98%. The results of research conducted by
Sarfika, Keliat & Wardani (2012) where the provision of
cognitive therapy alone can reduce depression by 71.97%. The
results of another study conducted by Pasaribu (2012) showed
that depression after being given cognitive therapy decreased by
(35%). Cognitive therapy given to clients with depressed
conditions can reduce depressive conditions. Psychological
factors that play a role in depression are feelings of helplessness,
hopelessness, role conflict, anger, shame about changes in body
image and denial of disease. This condition is a response that
arises due to negative perceptions in clients with stroke.
Negative perceptions are generated by distortions of thought.
Distortion is produced by situations that are unpleasant,
uncomfortable or threatening. Someone who tends to process
information with a negative mindset will produce a pathological
scheme so that they tend to remember negative information
(Kring, Johnson, Sheri, et.al, 2010). Stroke clients tend to bring
up negative thoughts due to the impact of the stroke they are
experiencing. Therefore it is necessary to be given training to
help change negative thoughts into positive thinking patterns.

In the group that was not given the intervention, the depression
condition before the intervention was 20.59 (32.68%) to 19.34
(30.69%), there was a decrease in the depressive state but it was
still in the moderate depression range. Depression decreased by
1.99%. This insignificant decrease occurred due to emotional
responses that appeared in stroke clients due to their physical
conditions. The client has not accepted the physical condition he
is experiencing. The client has not received a loss of physical
function from disabilities that arise due to the impact of stroke.
The client has not been able to accept his physical condition after
having a stroke.

There was a decrease in depressive conditions in clients who

received cognitive therapy and family psychoeducation but not
100%. Family psychoeducation therapy here focuses more on
solving problems faced by families when caring for stroke
clients. Most of the families caring for stroke clients disclosed the
emergence of problems in caring for clients such as time
burdens, financial burdens and difficulty resting because they
were anxious about the client's condition.

The success of giving cognitive therapy to reduce depressive

conditions is not very significant, this can be caused by other
factors such as the number of meetings that are still insufficient
to help clients identify as many negative thoughts as possible so
that these negative thoughts no longer exist in the client.
Depressive symptoms with 20 sessions are estimated to be able
to reduce 75% of signs and symptoms of depression in clients
combined with behavioral therapy (Varcarolis, 2010). Cognitive
therapy stops when there are no negative thoughts in the client.

Cognitive therapy is a method that can be used to increase the

ability to change negative thoughts. Meanwhile, family
psychoeducation is a therapy that can provide information and
education through therapeutic communication that supports
treatment and rehabilitation. Cognitive therapy was originally
used to treat depressive conditions, and is now being used to
treat emotional disorders and other clinical conditions such as
panic disorder, general anxiety disorder, social phobia, obsessive
compulsive disorder, PTSD, eating disorders, drug addiction,
personality disorders, schizophrenia, partner problems, bipolar
disorder, hypochondriasis, and somatoform disorders (Beck,
1995; Saddock & Saddock, 2007; Wright, Thase, & Beck, 2008;
Townsend, 2009). In clients with a stroke, emotional changes
such as anger, fear, anxiety, depression, emotional paralying,
hopelessness and helplessness can appear. If this condition is not
resolved, it can aggravate the client's psychological condition.
The events experienced by clients make it important to increase
the client's ability to control negative thoughts so that the impact
of psychosocial problems that arise can be overcome. Another
goal of cognitive therapy is to help clients think about their
disease objectively in an adaptive way.

Wills & Fegan (2001, in Safarino, 2006) stated that family

support refers to the assistance that individuals receive from
other people or groups around them that make the recipient feel
 comfortable, loved and appreciated and can have a positive effect
on him / her. Increasing family support can be a strategy in
reducing or preventing mental stress and warding off post-
stroke depression (Salter, Foley & Teasell, 2010). The purpose of
providing cognitive therapy and family psychoeducation is to
help clients overcome depression and helplessness by increasing
the ability to change the client's negative thoughts. In the group
that received cognitive therapy and family psychoeducation, the
increased ability to change negative thoughts was not too
different from the group that only received cognitive therapy.
This is because stroke clients who have a disability condition
suddenly need a long process to return to their original state.
This is what causes changes in emotions and feelings to stroke
clients.

The success of giving cognitive therapy and family

psychoeducation is due to the fact that at each session the client
is trained to fight negative thoughts that arise. Besides that, in
session 4, the existence of family support that helps remind
clients to do exercises against negative thoughts also has an
impact on the success of therapy. The provision of cognitive
therapy and family psychoeducation was able to increase the
ability to change negative thoughts in stroke clients more
significantly than in clients who only received cognitive therapy.
Family support is very important for stroke clients. Family
support here can be in the form of psychosocial support such as
attention, compassion and empathy (Bonar, 2004).

b. The Effect of Cognitive Therapy and Family Psychoeducation

on Depression Conditions.
The results showed that there was a significant decrease in
helplessness after intervention after cognitive therapy and
family psychoeducation was seen from the increase in the score
of helplessness. The score of helplessness before being given the
intervention was 61.21%, increasing to 68%. There was an
increase in the score of 6.79%. The expected score increase is
100%, which means that the higher the score for the client's
condition, the more empowered the stroke is. The responses that
arise from helplessness consist of verbal, emotional responses,
participation in daily activities and responsibility for self-care
(Miller, 1991). NANDA (2010) defines that helplessness is the
perception that a person's actions will not significantly affect the
results, perceptions of the current situation or situations that
will occur soon. It can be said that helplessness is a deficit of
internal and external control over the individual or client's
perceptions of helplessness which is verbalized explicitly in the
form of emotional and behavioral changes.

By providing cognitive therapy and family psychoeducation, it is

hoped that it can reduce the helplessness experienced by stroke
clients. In this study, the score of helplessness after giving
cognitive therapy and family psychoeducation increased only by
6.79%. Stroke is a disease caused by neurological changes due to
disruption of blood flow to the brain. The impact of stroke in
general is disability that makes stroke clients experience
limitations in their daily activities. The client feels lost due to his
previously good physical condition being unable to carry out
daily activities. Clients tend to depend on other people, causing a
feeling of helplessness. In the first session of cognitive therapy,
there is an expression that the client cannot do anything with his
physical condition, the client is ashamed of disability and cannot
do anything, the client repeatedly, the client is annoyed that his
hands and feet cannot be moved, the client feels guilty to bother
others. It can be seen that the client has not accepted his physical
condition, which used to be healthy, has become limited in
carrying out activities and there is a sense of guilt from the
client's condition.Thoughts affect the mood, feelings and
behavior of stroke clients. Cognitive therapy aims to change
negative thoughts into positive ones and focus on the current
situation.

Family is the client's source of coping in dealing with the client's

illness. With family support, it can help depression in stroke
clients in accepting their physical condition. Lack of family
knowledge about the client's illness can adversely affect the
psychological response experienced by the client and the family
itself.

Another study conducted by Widuri (2012) where acceptance

and commitment therapy (ACT) reduced the condition of
helplessness in clients with CRF. The results of another study
 conducted by Mc Cracken (2011) on chronic disease in the
intervention group after Ability to Change Negative Thought
before the intervention in Client Stroke given ACT therapy with a
follow-up for 3 months showed a decrease in the level of
depression, anxiety, the intensity of chronic pain experienced,
increased physical abilities and became more psychologically
flexible in dealing with stressors related to their condition.

c. The Effect of Cognitive Therapy and Family Psychoeducation

on the Ability to Change Negative Thoughts
The results showed that the ability to change negative
thoughts in stroke clients who received cognitive
therapy and family psychoeducation before receiving
intervention was 61.07 (43.62%), increasing to 72.76
(51.97%). Cognitive therapy is a basic therapy and is
very influential in increasing the client's ability to
change negative thoughts, while family psychoeducation
therapy is a complementary therapy to help individuals
practice the ability to change negative thoughts.

Beck, et al (1987) in Townsand (2009) explain that the

goal of cognitive therapy is to monitor negative
automatic thoughts experienced by clients by
recognizing and correcting wrong thoughts, affective
and behavior and changing interpretations towards more
reality and learning to identify and change beliefs.
wrong as a result of a bad experience or situation.
Burn (1980) explains that negative thoughts come from
unpleasant or threatening events such as decreased
physical conditions, the impact of treatment, causing
fear, loss, disability, dependence.

The results of the research by Sarfika, Keliat, Wardani (2012)

that there was an increase in the ability to change negative
thoughts in DM clients who received cognitive therapy and
logotherapy by 42.06%. Increased ability to change negative
thoughts occurs because clients are trained to fight negative
thoughts that arise due to negative perceptions of the client's
illness.

Cognitive therapy can help clients improve their ability to change

negative thoughts so that they can minimize distress due to
disturbing, anxious and threatening thoughts. Clients can replace
negative thoughts with more realistic thoughts that are in
accordance with the client's current condition. Renfrow (2006)
explains that cognitive therapy is effective in overcoming
depression which focuses on modifying cognitive distortions and
correcting maldaptive thoughts and changing negative thoughts.

Kraus (2012) states that clients with emotional disorders such as

depression tend to experience negative automatic thoughts,
where the client has an emotional response that generates many
negative thoughts which are automatically stored in their
memory without being analyzed rationally and logically.
According to Hollon and Kendal (1980), individuals who have
negative thoughts show feelings of being unable to adjust to the
desire to make life changes, have negative expectations and
negative self-concepts, are inferior and give up easily. This is also
found in stroke clients.

CONCLUSIONS
Clients in this study were more men, with an average age of
54.85 years, highly educated, most of whom did not work and on
average suffered a stroke of 15.49 days. Depression conditions
before intervention in stroke clients amounted to 30.38% and
the condition of helplessness was 59.76% and the ability to
change negative thoughts was 52.67%. Depressive conditions
after being given therapy to clients who received cognitive
therapy and family psychoeducation experienced a decrease and
were in a state of mild depression, a decrease of 6.08%. The
provision of cognitive therapy and family psychoeducation
reduced the condition of helplessness by increasing the score of
helplessness by 6.79%. The provision of Cognitive Therapy and
Family Psychoeducation increased the ability to think positively
from 43.65% to 51.97%. Cognitive therapy increased the ability
to change negative thoughts in stroke clients by 3.93. The ability
to change negative thoughts is associated with depression. The
ability to change negative thoughts has nothing to do with a state
of helplessness.

It is necessary to have a mental specialist in a public hospital and

collaborate with other specialists such as medical surgical
nursing so that clients with stroke who experience depression
get holistic nursing care and can help the healing process to be
 better. The results of the study prove that the combination of
cognitive therapy and family psychoeducation can be used to
help reduce psychosocial problems, especially depression and
helplessness and increase the ability to change negative
thoughts. The results of this study can be used as evidence based
in comparing the effectiveness of various therapies that can be
given to stroke clients with depression and helplessness. There is
a need for research that combines specialist cognitive therapy
and family psychoeducation with logotherapy to achieve changes
in conditions of anxiety and helplessness in stroke clients.

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